Study: Relapse prevention medications like Vivitrol and Suboxone used in drug courts have minimal impact on recidivism

CLEVELAND, Ohio - A new evaluation of more than two dozen Ohio drug courts found that the only apparent result of giving participants medication for addiction was that some stayed in the court programs longer.

Beyond that, the state-funded study found,use of Medication Assisted Treatment, or MATs, had an otherwise minimal effect on two important outcomes: continued drug use and recidivism.

Since 2013, lawmakers have sunk more than $33 million into introducing MATs into drug courts, including $1 million it paid Treatment Research Institute, of Philadelphia, for the most recent evaluation that looked at about 600 drug court participants in 13 counties.

The tepid results, however, haven't dampened support for the use of MATs in Ohio's criminal justice system.

In an Aug. 22 letter sharing the findings with lawmakers and state agencies, Ohio Mental Health and Addiction Services (OMAS) Director Tracy Plouck said a majority of those running the programs "reported that they would strongly encourage others to start using MAT, but emphasized that MAT alone is not enough and it should be combined with evidence-based psychotherapy."

Plouck also shared that the study found some health care savings -- $4,384 on average - for individuals in the programs. The state program is limited to Medicaid- eligible individuals charged with non-violent felonies who are opiate or alcohol dependent.

The Medicaid savings, officials said, likely stem from less use of emergency services for things like non-fatal overdoses.

Currently, close to 90 Ohio Supreme Court-certified adult and juvenile drug and recovery courts serve more than 5,000 participants each year.

State grants that provide MATs have expanded to 31 of those courts and pay for addiction treatment and related costs, like transportation and housing.

The state is investing in MATS as an evidence-based practice because larger studies have concluded that there is a better chance of recovery if some sort of MAT is involved, said Jamie Carmichael, acting deputy director of public affairs for OMAS.

Since Medicaid expansion, the use of MATs to help treat addiction in Ohio grew to $110 million last year.

Read more about Ohio's use of MATs

Rep. Robert Sprague, a Republican from Findlay, said the state wanted to find a way to introduce MATs four years ago and lawmakers thought drug courts would be a good fit, which he said the evaluation supports.

"It is helping people to stay in the drug court, which is good because we know the drug courts work," Sprague said.

The evaluation looked at about 500 drug court participants involved for at least six months, some who received medications and counseling services and who weren't able or chose not to take medicine but received substance abuse counseling and other services.

It found:

75 percent of individuals (263) who received medications were active or graduated.

73 percent who did not receive medications were active or graduated.

Medication comparison not possible

One goal of the study was to determine which type of Medication Assisted Treatment (MAT) was most effective for people in the criminal justice system.

It's an issue courts and lawmakers have struggled with as medication has been slow to gain acceptance by police, jails and courts for use in treatment of addiction.

That comparison was not possible, however, because 89 percent of the participants who received MATs, an overwhelming majority, took Vivitrol, a monthly opioid-blocking shot.

The shot, which costs about $1,000 for each dose, has been aggressively marketed to courts and Ohio lawmakers by Alkermes, which produces the medication at a factory in Wilmington. The company often offers courts free initial trial doses of the medication.

Vivitrol is favored in the criminal justice system over medications like buprenorphine and Suboxone, which have a street sale value, and methadone, which is more tightly regulated and less available. Those medications, called partial agonists or agonists, work differently, satisfying opioid receptors in the brain, rather than blocking them.

It appears from the Treatment Research Institute report that in many programs, including Cuyahoga County's drug and recovery courts, Vivitrol was the only option offered.

Karen Dugosh, who authored the report with colleague David Festinger, said the reliance mainly on the Vivitrol shot prompted a recommendation that more education was needed in the criminal broader community about the other medications to "increase acceptability" of the full range of treatment options.

Dugosh also said that of the 13 people who died during the evaluation period, 12 were not on medication and one had received Vivitrol.

A National Institute of Drug Abuse-funded study comparing the difference, if one exists, of relapse in people taking Vivitrol and Suboxone at eight community treatment centers, including one in Ohio, is expected to be released this fall.

What do we know about MATs

Same results

Overall, Treatment Research Institute's results were largely similar to those found during an evaluation of the state's pilot project, completed for $200,000 in 2015 by Case Western Reserve University's Begun Center for Violence Prevention Research and Education.

The Begun Center study previously found that being exposed to violence, as a victim or witness, was the most significant indicator that a person in the programs would be re-arrested.

The Begun Center's report also cautioned of a higher rate of unintended pregnancy for women taking MATs, an issue drug courts across the state have struggled with.

(In Hocking County, drug court participants who are women must agree to take birth control to be in the Vivitrol Drug Court. Other courts counsel women of the risks of becoming pregnant while taking the various medications.)

Drug court officials and community treatment providers, called "networks" in the evaluation, said many counties still lack enough access to detoxification services and treatment, including MATs, and options for sober living.

Despite more court systems allowing or encouraging the use of FDA-approved medications to treat addiction, many in the wider community -- especially those wedded to abstinence-based recovery, such as AA or 12-step programs -- continue to view medication as a crutch.

Carmichael said the next step is to educate the criminal justice system on all forms of MAT through 10 symposiums across the state next year, paid for with money from the federal 21st Century CURES Act, from which Ohio will get up to $26 million.

In addition, she said the state is allowing more flexibility for how drug courts can use grant money, and they are expanding medication options to include the more tightly regulated methadone.

"Our goal is to really figure out how to provide access to whatever kind of treatment people need," she said.

More options needed

In Cuyahoga County, Common Pleas Judge David Matia, who oversees one of the two drug court dockets, strongly supports expanding the availability of MATs, particularly opiate-based medication assisted treatment, like buprenorphine.

While he says the TRI study might raise more questions than it answers, state grants have been beneficial to introducing MATs to Cuyahoga County's criminal justice environment and spurring larger conversations about building capacity to help treat people starting when they are in the jail and then as they continue through the courts and when they are back in the community.

"We wouldn't be where we are today without it," Matia said.

Although Vivitrol is currently the only option available under the grant in Cuyahoga County, Matia said he believes buprenorphine might hold more promise for treating opioid-dependent individuals within and outside of the criminal justice system.

"I think all options at this point need to be on the table because people are dying," Matia said.

Which is why Ohio still needs to spur more innovation in the treatment system, Sprague said in a phone interview.

Rather than doing that through the legislature, Sprague is in favor of facilitating innovation, possibly through a social impact bond, which is basically an investment in an idea where cost savings are used to pay back the initial investment.

"At this point we're looking at anything that sounds remotely feasible," he said.